Summary On 6 September 2000, the owner/operator of an aluminum trawler was fishing alone off the mouth of the Fraser River, British Columbia. During the daytime harvesting operation, it appears that elements of his protective clothing became entangled in the net, and he was drawn into the turning main net reel. He died as a result of his injuries. Ce rapport est galement disponible en franais. Factual Information Particulars of the Vessel Description of the Vessel Built in 1995, the StarQueen is a commercial dragger-gillnetter. The hull and the superstructure are of all welded aluminum construction, and there is one fixed pitch propeller, driven by an inboard engine. The wheelhouse and cabin structure are arranged forward of midships, while the after hull section comprises the working area, with deck machinery and access covers to the cargo compartments, fish holds, and stowage lockers. The vessel's deck is made of aluminum and includes flush deck diamond-patterned plates covering the cargo or bait compartments that provide non-skid properties. The deck beneath the trawl winch is about 0.75metres lower than the main deck and extends to the after bulwark. History of the Voyage On the morning of 6September2000, the owner/operator of the StarQueen set off to fish in the Sandheads area, around the mouth of the Fraser River. He wore bib-styled rain pants and rain jacket over his clothing. Though alone on his vessel, he sailed with a friend who was on board another trawler. As the two searched for ground fish, they remained within sight of each other until about 12002, after which they drifted apart. At around 1600, when the second operator had not seen or heard from the StarQueen for some time, he set out in search of the vessel. At about 1800, he located the StarQueen aground on a sand bank. The operator lay collapsed and supine on deck, with his left leg entangled in the winch drum and net. The trawl net itself was over-wound on the starboard side of the drum and had spilled over and wrapped itself around the sprocket gear and shaft. The winch drum was still turning at the time of the discovery. The second operator raised the alarm by issuing a Mayday signal on VHF channel 16. The distress message was picked up by Marine Communication and Traffic Services (MCTS) and forwarded to the Rescue Co-ordination Centre in Victoria. MCTS made a Mayday relay of the situation and at 1820, a third craft which was in the vicinity found the StarQueen and the second fishing vessel rafted together and was able to confirm the distress position. At 1835 Canadian Coast Guard Search and Rescue was on the scene, and though resuscitative efforts were immediately initiated, the owner/operator succumbed to his injuries without regaining consciousness. He was taken to hospital where he was pronounced dead on arrival. Description of the After (Working) Deck Figure 1. Sketch of the after deck. The working deck extends aft from the wheelhouse structure, to the stern of the trawler (seeFigure1). An hydraulically-operated boom is located abaft the wheelhouse, together with two hydraulic trawl winches, one on the port side and the other on starboard. A hatch for access to the main fish (cargo) hold, is located on the centre line, aft of the boom, and an open working space is aft of the hatch. The after deck area, part of which forms a well, is located under the drum of the main net storage winch. A second set of engine and rudder controls, used during fishing operations, are arranged on the port side, outboard of the winch. The control valve and handle to govern the speed and direction of rotation of the main winch motor is arranged under the bulwark on the port quarter. A remote start/stop device (hold-to-run control) to the hydraulic winch motor is fitted under the bulwark around the stern. All the controls are arranged ergonomically around the operator's stand. Description of the Remote Stop Device Also known as a hold-to-run-control, this is an emergency shut off device that is designed to automatically and immediately stop the main net winch in the event the winch operator becomes incapacitated. It seeks to prevent injury to the operator. It also finds frequent use, especially while hauling in the net, as a remote switch for starting and stopping the winch. Essentially it consists of an horizontal, hinged lever, set up at deck level, so that it can be controlled by the operator's foot. Use of the foot-controlled lever leaves the operator's hands free to operate the various steering, engine, and winch controls. The lever is spring loaded and has a system of cables and linkages connecting it to the control valve of the winch motor. As long as the operator's foot keeps the lever depressed, the winch turns. As soon as foot pressure is released, the tension in the spring returns the remote stop device to the normal position, which returns the control valve to neutral and stops the winch motor. Prior to the occurrence, the hold-to-run-control of the StarQueen had been disconnected from the winch control valve, leaving the emergency shut off device inoperative. Description of the Hydraulic Motor and its Controls An hydraulic motor provides the motive force that enables the trawl net reel to rotate. It is mounted on the port side of the drum and two fixed high pressure hoses supply it with high-pressure hydraulic oil via the control valve located on the port side bulwark. The speed and direction of rotation of the winch are primarily controlled by the control valve. On the StarQueen an additional bypass valve was fitted between the high pressure and return lines, in such a way that when the open position is selected, the hydraulic oil is routed away from the motor and the winch does not rotate. When the bypass valve is closed, it allows pressurized oil into the motor which turns the winch. This valve is a second means of controlling the operation of the winch. The bypass-valve is used to quickly pay out the net. After disconnecting the hydraulic pump, the net drum can freewheel while the vessel is moving ahead. The bypass valve is mounted directly on top of the hydraulic motor itself, on the port side of the drum, and its handle is located between the two hydraulic pipes. It can be reached from the operator's stand described above. In addition, it can also be accessed by a person standing at the centre of the winch drum, when the net is fully deployed by reaching over and across towards the port side. This however, is a relatively awkward and inconvenient way of reaching it. There is no guard or protective plate between the side of the drum and the bypass valve. The general state of maintenance of the control valve was found to be poor; it was found to be leaking hydraulic oil. It is reasonable to assume that it had been malfunctioning for some time. The handle was hard to move and it did not automatically return to the central neutral position when released. Two external springs were found in the vicinity of the handle, one at the top and the other at the bottom, but disconnected from it. The working deck in the area of the control valve was covered with hydraulic oil and was quite slippery. Vessel Certification, Training and Personnel History Being a fishing vessel under 15 gross registered tons (GRT), the StarQueen is exempt from undergoing a quadrennial inspection and being issued a Ship Inspection Certificate by Transport Canada. The owner/operator was not required to hold a Transport Canada certificate to command a fishing vessel of this size and type. He was well experienced in the fishing trade both in Canada and abroad, before immigrating to Canada. He had been a fisher in Vancouver for over ten years, five of which were as joint owner of another fishing vessel and five as sole owner of the StarQueen, which he had purchased new.